Pre-op Form

Complete this form if you will be undergoing a procedure and consent to Anaesthesia. This form is required to fulfill the criteria for surgery. All information is sought to minimise your risk and will be retained by the Anaesthetist as part of your confidential clinical record.

Please answer all questions as accurately as possible.

First name *

Last name *

Address *

Day contact number *

After hours contact number *

Do you have an email address? *

No

Yes

Date of birth *

NHI number

Are you a New Zealand resident *

No

Yes

Gender

Male

Female

Not stated

Are you or could you be pregnant? *

No

Yes

Weight (KG) *

Height (Metres) *

Doctor’s name *

Practice name

Contact number

Proposed surgery *

Surgeon *

Anaesthetist

Date & Place *

ACC Claim *

Yes

No

Self-pay

Have you had previous surgery before? *

No

Yes